Johns Hopkins' senior hospital epidemiologist and flu expert is calling for mandatory vaccination of all health care workers as the best means of protecting patients and hospital staff from widespread outbreaks of the viral illness. Studies by other United States researchers show that voluntary vaccination programs don't do the job and that each year, nearly 40,000 Americans die from influenza, many of them elderly or ill, with weakened immune systems that cannot readily fend off the disease.

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Johns Hopkins' senior hospital epidemiologist and flu expert is calling for mandatory vaccination of all health care workers as the best means of protecting patients and hospital staff from widespread outbreaks of the viral illness. Studies by other United States researchers show that voluntary vaccination programs don't do the job and that each year, nearly 40,000 Americans die from influenza, many of them elderly or ill, with weakened immune systems that cannot readily fend off the disease.

In an editorial to be published in the journal Infection Control and Hospital Epidemiology online Nov. 9, Trish Perl, M.D., M.Sc., concludes that mass vaccination policies are required to prevent patients from accidentally contracting the virus directly from an infected medical staff worker or indirectly from other patients or visitors via medical staff.

Previous research from Hopkins showed that annual flu shots have been almost 88 percent effective at reducing the risk of flu infection and that they reduced by one-half the number of deaths among hospital patients from the disease.

Perl's view, which is likely to inform further debate on the subject of voluntary versus mandatory worker vaccination programs, is based on research showing that despite free and ready access to the vaccine, only 40 percent of all health care workers actually get a flu shot.

"We have gone as far as possible with vaccination programs emphasizing education and health promotion," says Perl, an associate professor of medicine and pathology at The Johns Hopkins University School of Medicine. "It's now time to go the extra step, requiring active declination or even making vaccination a mandatory part of the job, linked to patient safety, along with such tasks as keeping hands clean and getting mandatory TB tests."

Neither state nor federal law requires workers to provide medical details when they call in sick so it is difficult to precisely link seasonal hospital absenteeism and high rates of non-vaccination, she notes.

"We need to close the very serious gap between knowledge and behavior that exists among health care workers," Perl argues, and it can be done, she says. In 2003, her team, along with occupational health services, at Hopkins vaccinated more than 70 percent of 10,000 hospital staff. "But we can do better and, ideally, at Hopkins and other hospitals, our objective would be to consistently have more than 90 percent of staff vaccinated each year."

According to Perl, numerous staff surveys from other hospitals have shown that the most common reason cited for not getting a vaccination is a lack of time (47 percent). Surprisingly, a remarkably high number of staff, more than 30 percent, believed they could catch influenza from the vaccine itself, which is false.

Perl also notes from surveys that relying on people's self-awareness is not sufficient to prevent the flu from spreading. "One-half of infected health care workers have no idea when they are infected with influenza, often having few if any signs and symptoms and making it impossible to ask all staff to stay home when they are feeling ill to prevent other people from catching their infection," she says.

Still other studies have found that education campaigns can be effective at increasing vaccination rates among health care workers by as much as 60 percent. And to the surprise of those conducting these surveys, the reason most likely to motivate health care workers to get the shot is that it benefits patients, not themselves.

However, in the editorial, Perl concludes that, "'Shifting the message from self-interest to altruism in protecting patients may improve vaccination rates, but it won't fix the problem. From a hospital policy standpoint, this is a real patient safety issue and vaccination can be viewed as a means of protecting patients from influenza exposure and the related mortality seen among vulnerable populations. Vaccination should be presented as such to both health care workers and every hospital's leadership."

Perl notes that even without mandatory vaccination policies, other potential barriers to widespread vaccination can be helpful and should be implemented nationwide. Among her recommendations are free shots for all staff, easy access to flu shot clinics on site, flexible vaccination hours, emphasis on patient safety aspects of the program, education to counter beliefs that the shots can make you sick and encouragement from hospital leaders to get the vaccine.

The next step, Perl says, is for health care professional associations, such as the Infectious Disease Society of America and the U.S. Joint Commission of Accreditation on Healthcare Organizations, to endorse mandatory flu shots. One group, the Society for Health Care Epidemiology, last month endorsed just such a plan. However, she acknowledges that current federal workers' rights prevent employers from making vaccinations a requirement.

Perl says her proposal is open to discussion at Hopkins. "Ultimately, we want to make vaccination as mandatory for workers as the law allows in order to effectively accomplish what we cannot enforce," she says.

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